Chapter 41. Mandible Reconstruction

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Mandible Reconstruction

Presenter: Int.

Date: 2012.09.24

Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne

Chapter 41


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Outline

Introduction

Methods of reconstruction

Free-Flap Donor-Site Selection

Preoperative Planning

Surgical Technique

Postoperative Care

Complications

Other Postoperative Issues


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Goals of Reconstruction

Function

TMJ: maximal opening ability and maintenance

of occlusion

Normal interarch distance and alignment

Aesthetics

Symmetry

Lower facial height

Anterior chin projection

Submandibular soft-tissue neck defects3


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Etiology

Cancer

Epidermoid carcinoma

Benign cystic or fibrotic bone diseaseTrauma

Gunshot wounds

Infection

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Classification of Mandible Defects

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Osteocutaneous Free Flap

Most effective

Soft tissue + bone

Microvascular anastomosesPedicle qualities: vessel diameter and

length

Survival rates: 95%

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Ilium

Radius

Scapula Fibula

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A: Scapula

B: Ilium

C: Radius

D: Fibula


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Ilium

Advantages

Abundant bone

Segmental blood supply from the deepcircumflex iliac artery, allowing segmental

osteotomies

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Ilium

Disadvantages

Bone with predetermined shape

Less robust, even marginal circulation at distal

end

Unreliable circulation to skin island

Bulky and less mobile soft tissue

Arduous closure at donor site

Donor site morbidity: hernia, attenuation of

the lateral abdominal wall, painful, limit early

mobilization 11


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Ilium

Indication

Short lateral or hemimandible segment not

requiring mucosal lining replacement

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Radius

Disadvantages

Worst bone quality

Post-operative fracture

Limited segment (10 cm): between insertion of

the pronator teres and the brachioradialis

Insufficient soft tissue

Poor donor site appearnce

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Radius

Indication

Bone defect limited to the ramus and the

proximal body with a large associated intraoral

soft-tissue defect

Soft-tissue free flap without bone coverage of

a metal plate

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Scapula

Advantages

Greatest amount of soft tissue (30 cm, include

latissimus dorsi)

Independent bone and soft-tissue components

14 cm of bone available

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Scapula

Disadvantages

No segmental blood supply

Donor site location: delay in flap harvest

Compromised shoulder function

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Fibula

Advantages

Bone: adequate length, height, thickness and

straight quality ideal for shaping

Functional segmental blood supply

Good vascular pedicle

Flexor hallucis longus muscle

Reliable skin island: 91%

Most convenient

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Fibula

Disadvantages

Unreliability of the skin blood supply: 9%

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Fibula

Indication

All anterior defects and most lateral defects

Flap of choice for the majority of mandible

defects

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Preoperative Planning

Cardiopulmonary evaluation: pulmonary

function studies and cardiac stress testing

Consult dental service: intermaxillaryfixation, intraoperative tooth extraction,

splints fabrication and prosthetic

rehabilitation

Aesthetics: CT (1:1) and MRI

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Surgical Technique

Donor site dissection

with ablation in progress

Graft shaping with ablation in progress or after

Bony fixation

Microvascular anastomoses Final wound closure

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Graft Shaping

Lateral graft shaping

Angle of mandible

planned where vascular

pedicle enters the bone

Condyle harvested from

the surgical specimen

Anterior graft shaping Central segment first

Transverse template

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Bony Fixation

Miniplate: efficient, safe and strong

Reconstruction plate: does not allow subtle

nuances of mandible shape Interosseous wires: not enough resistance

Intermaxillary fixation: maintain occlusion

External fixator: no longer popular

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Microvascular Anastomoses

Artery

Facial artery

External carotid (end-to-side)

Superior thyroid artery

Vein

External jugular vein

Internal jugular vein

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Postoperative Care

Early mobilization

Tube feeding begun in 48 hours

Irrigation for oral hygiene begun after 1week

Tracheostomy left in place for 10 to 14 days

Doppler ultrasonography

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Complications

General medical problems

Pulmonary and cardiac problems

Head and neck wound problems Free-flap failure (total flap loss < 5%)

Reconstruction plate exposure

Intraoral wound dehiscence

Donor-site problems

uncommon

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Thanks for your attention!

Presenter: Int.

Date: 2012.09.24

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Chapter 41. Mandible Reconstruction